Losing Lives to Save Lives: Targeting Humanitarian Workers in Conflict Zones

Jason Cone

Executive Director, Doctors Without Borders/Medecins Sans Frontieres USA

Yves Daccord

Director-General, International Committee of the Red Cross

Leonard Rubenstein

Director, Program on Human Rights, Health, and Conflict, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health

Laurie Garrett

Senior Fellow for Global Health, Council on Foreign Relations


Experts discuss current threats to global health workers in crisis zones, and what can be done to stop attacks on humanitarian workers to ensure their safety and neutrality.


GARRETT: Some of you may have seen this this astounding article that appears in the current issue of The New Yorker, by Ben Taub, “The Shadow Doctors.” Blow-by-blow description of what it takes to provide health care inside the boundaries of Syria today. And among those that are directly supporting and making all that possible is Médecins Sans Frontières, or Doctors Without Borders. From that organization, we have the American President Jason Cone with us. Also making this possible through provision of supplies and personnel is the International Red Cross. And from Geneva, we have with us today Yves Daccord, also to speak to this.

Some of you may have noticed that WHO has stepped up its game on this issue quite recently. For a long time, there was criticism that the WHO was silent, by and large, regarding attacks on health care workers, leaving it to the sort of Amnesty International genre and human rights trackers to make comment, or to MSF. But recently WHO released its first serious accounting of the numbers of attacks they have been able to confirm in 2014 and 2015 that targeted health facilities and health care providers. They say that in the two-year period, 2014 to ’15, nearly 600 health facilities were placed under direct attack, killing more than 950 patients and health providers.

That they are now tracking regularly, and just issued a report yesterday denouncing the government in Libya for multiple health facilities placed under attack this week in Benghazi. And we have another report that has been issued that involved several different NGOs in academic settings, reviewing the details of these attacks and adding to the list far more than WHO has quantified. And one of the instigators of that report, Leonard Rubenstein, is with us, from Johns Hopkins.

So what I want to do is walk through a few issues for about half an hour with the panel, and then open it up to all of you. And as I say, please feel free to tweet any comments, any thoughts.

Jason, let’s start with you. We had a lot of hope that once a real fight went before the United Nations Security Council and the Security Council passed, what is it, 2286, relatively recently, which gives specific language basically reinforcing the Geneva Convention and saying under the Geneva Convention all of this should never be happening—there was hope this could lead to something, this could somehow soften the blow, as it were. What’s your read on what has actually been the impact, and why we see what appears to be a trend of increasing state-approved attacks on health care workers, health facilities, convoys of medical supplies, and so on?

CONE: Thank you, Laurie. And thanks for organizing this panel. And I think as Médecins Sans Frontières, we didn’t have any sort of real illusions that the resolution was going to change anything immediately. It was really about sort of reaffirming those basic commitments in the Geneva Conventions and others that medical care workers, the patients they serve, the hospitals they work in, ambulances, shouldn’t come under attack. And it was very much, as you said, a response to a worrying trajectory that we see whereby the very architects of the system that we have today that’s meant to preserve and protect peace and order in the world are very much linked into coalitions that have been behind these attacks. It’s not just the Syrian regime, although, obviously, that has been a place where we’ve seen these protections pretty much eviscerated since the start of the war.

So for us, it was incredibly concerning. And that’s why my colleague, Dr. Joanne Liu, joined Dr. Peter Maurer from the ICRC to sort of stand—to really stand back and join in the passing of that resolution to really denounce it. But the reality is today as we saw in Benghazi, as we see today in Aleppo and elsewhere, it hasn’t changed much on the ground. And so there is real risk that even less than two months since the passing of the resolution, that it becomes part of the empty rhetoric that we somehow see coming out of not too many block away from here at the U.N. So it’s for us as workers on the ground to continue to be a check on the powers that have created the conditions in which these kinds of attacks can happen.

Much has been made about the role of ISIS and other non-state actors. They certainly have responsibilities. They have been—as the New York article attests to, have even kidnapped and abducted some of my colleagues, and prevented us from being able to work in areas under their control. So they have responsibilities. But that also falls on the shoulders of the permanent members of the Security Council to follow through on the resolution, to make sure that it’s not just words on paper.

GARRETT: Well, words on paper, but if—well, first, let’s make the distinction. The sort of terrorist actions, the renegade militias, the ramshackle operations going around and shooting guns and making demands on health providers versus state actors, it does seem like the majority of the increase is actually by state actors not by so-called terrorists. Are they using the threat of terrorism as an excuse to obviate their commitments under the Geneva Convention?

CONE: Yeah, I think—I mean, we’re in a sort of watershed moment where we look at, I think, two really converging forces that we have. One is that, you know, real threats are being placed on the right to assist people, whether they are doctors. So you see a trajectory where providing medical care to people in areas controlled by the same groups we just talked about, or even those who are wounded combatants is seen as a criminal act. That’s what was passed in July of 2012 in Syria. We see it played out elsewhere. So you have this attack on the ability of doctors, aid workers, to be able to assist people.

And then on the other side, we have—which is on the refugee crisis, the migrant crisis, you have a continuing situation where we have—whether it’s the European Union in Turkey, whether it’s Kenya with the Dadaab camps, an externalization—you know, pushing people back into the heart of crisis. So if I’m a victim of a conflict today, I face the reality that the people who assist me will be killed, attacked, tortured. And on the other side, if I actually escape, I will be pushed back.

And so for me, those are policies orchestrated by the states that run the international multilateral system. And that’s a very worrying trend, for us and those on the ground, I think. And the work that Len has done sort of cataloguing these things, it puts us a very precarious situation. But first and foremost, it puts the patients and the people trapped in these conflicts on really shaky ground for the future.

GARRETT: Yves, this does seem to be a pivotal moment, where the civilian in need is perceived as a threat to the place they may try to flee to—whether they’re fleeing in order to get cancer care for their child or they’re fleeing in order to get away from bombs, bullets, it almost is irrelevant. The Brexit vote and so on signal a sense in the nations they would flee to that they are the terrorists, they are the enemy. And meanwhile they, if they remain in their home, cannot receive any health care.

DACCORD: I think it is a pivotal moment. And if you allow me maybe two things. You just mentioned at the beginning is we see some prizes. But I think what is even more striking is today in Syria, if I look at ’16 and even last year, was the fact the worst year since the beginning of the conflict when it comes back to getting health care. We don’t have the beginning of the war, you know, more health and more people being attacked and then normally it calms down, on the contrary. So first thing what you understand from day one is that it’s systematically part of the strategy of the government and all party of the conflict to attack health care.

And it relates to what you said also. It relates to the fact that today civilians are not perceived at all as civilians, right? I mean, you try to control people. You try to really bring fear. You’re trying to—and the best way to do that is control health system. That’s what this is. So the pressure on health system is just dramatic. And that is something—we really need to grasp that. And in terms of mobilization is something which is absolutely dramatic, and link to with what Jason says.

What worries me a lot—and to connect that with the migration question—what we see is states which have been advocates for human rights and for international public in general, right, seems suddenly very lukewarm when it concerns their own territory and their own problems. And let’s be very clear, when you talk about Europe over the last few years, especially the last few months, what happened is the containment strategy that Europe was dreaming about—that if there is something happening down there in Middle East, far away, and somewhat by magic it’s contained. It will stay there. That has been broken over the last couple months.

And what is suddenly happening is you do not have any more convergence between the people, for us, the citizens, but also government about, you know, how do we deal with that? What are the right questions and the real questions we should ask ourselves? I’m coming from Europe, and I’ve really worked recently very hard with governments in Europe trying to understanding what are the questions when it comes to immigration, right? What is extremely striking right now is you have no political space in Europe at all to be able to ask ourselves or the government the right question.

And what is the right question in Europe? The right question is the following one: We will have in Europe every year between 2 to 3 million people which will come, if we like it or not. We can build walls. They will come. The question is, then, how do we integrate them? What type of social contract are we doing? How is Europe playing a positive role in Syria? How do we make sure that the Security Council can do something when it comes to Europe? How does Europe—but not only Europe, by the way—the permanent members of the Security Council, the non-permanent member of Security Council do the job, which is, in fact, to make sure that there are solutions happening, and we allow Syrians to choose not to leave Syria. That’s the critical questions.

And right now, what worries me a lot, to answer your question, is I don’t have the feeling that we have the right debate. We are just pointing, in fact, the fingers to the people. We put them in an extremely difficult situation, and we don’t look at responsibility. And that worries me quite a bit.

GARRETT: One of the trending Twitter hashtags is #NotATarget. And it reminds me that when I started out as a reporter covering wars, and so on, if one saw the Red Cross, that was neutrality. That was no guns, no bullets, this is a safe place. And if people made it to that Red Cross or the Red Crescent, they would be confident that they had reached safety. Now, that Red Cross or the MSF blue and white, or any of the many NGOs that are involved in humanitarian care, you become targets for kidnapping and held for ransom, targets for your convoys to be robbed by professional bandits or bombed by state actors. How did we lose control of the notion of something sacred about the Red Cross?

DACCORD: Can we just say, first of all, it’s a trend that we’ve seen over the last, let’s say, decade. And what strikes me the most is the following one: Is, A, we’ve seen more and more over the last, let’s say, 20 years, maybe, an evolution in warfare. A, we’ve seen that warfare is more about internal conflict. You have very, very rare international armed conflict—by the way, happily so. But you have a lot of internal armed conflict. You do have more and more urban conflict, which means conflict within urban area. And you do have, of course, asymmetric warfare because army structures and non-state armed groups, with all the questions relating to that.

And what you’ve seen over time is a real change in behavior—(coughs)—sorry—which leads, of course, to trying to control the population and control territory. So I think the question is not about us only. It’s about what does that mean for civilians? And what strikes me the most over the last few years is not so much that respect towards the Red Cross or MSF. It’s respect to basic elements of humanity—which is a hospital, a doctors—and the mere idea that you can treat your enemy. That’s what’s so interesting. That’s the basic. I mean, the humanity is really there. In war—even in war, you have limits. And what is the basic? The basic is when you have your enemy which is wounded you accept that this enemy is a human being and he needs to be respected. And you do respect that doctors can treat him or her, right?

And what strikes me right now is it seems this basic is not with us anymore. And I think here we really have to rebuild a taboo around that—a positive taboo. If we do allow, in fact, this to continue to be eroded, that the fact that hospitals are the first place that you would target, not the last one, then we do have a huge issue. We, as an organization, we have also to take more risk. We have to find a way. We have to engage. We cannot just complain, right? But that’s us as an organization. And there are ways to do that. There are solutions. We have to be humble. But what worries me much more is what happens to, in fact, health care, especially local health care. You see, if you look at the numbers of attacks right now, it’s not about the Red Cross or the International Red Cross or MSF. It’s about local health care, local structure—(inaudible). And that’s what is so worrying. (Coughs.) Sorry.

GARRETT: You know, for our participants who are here, they’ve all received copies of these dramatic photographs of a health facility literally carved out of a mountainside cave in Syria. For our webcast viewers, we make sure those end up on the CFR website for you to look at later. But I think it points a point that I want to talk to Len about. And that is, we’re not—we’re not talking here—and Yves has touched on this—we’re not talking here about some, you know, dramatic kind of health care, somebody getting a quaternary bypass surgery. We’re talking about the very basic human needs for access to health care being challenged because the provider of health care is designated a state enemy. For what crime? For providing health care. And how many countries, how pervasive is this around the world?

RUBENSTEIN: Well, it’s a really important question. In the report that Laurie alluded to about safeguarding health in Conflict Coalition we looked at 19 countries. And what we find, actually, is that there is an enormous variety of the kinds of interference. We know about Syria, which is directly targeting, but there are many other varieties. In fact, that probably the kind that might affect the most people are obstructions—obstructions of aid, obstructions at checkpoints—at places you wouldn’t think.

In the Ukraine it’s incredibly difficult these days for people living in the rebel-controlled areas of Ukraine to get medication. In the West Bank—we don’t hear anything about this—since the attacks on Israelis began in October, there have been reporting by the Palestinian Red Crescent, 300—more than 300 attacks on ambulances. In Yemen, we don’t think it was the Saudis targeting hospitals, but they didn’t bother to take any precautions when they dropped those bombs. So we have this incredibly wide kind of phenomenon—some by armed groups, some by states, some because, as in Syria which is really the most extreme case, where the medical facilities and the medical community are specifically targeted for political reasons. But we have many other kinds of situations.

It’s also not a new phenomenon. Way back I remember writing about hospitals in Chechnya being bombed. And I had a colleague, in fact we helped get him asylum in the United States, he was a doctor—a Chechen doctor, who was targeted by the Russians and the Chechens. Why? Because he provided health care to both sides. In Kosovo—what’s that, 20 years ago—100 clinics in Kosovo—it’s a very small country—100 medical clinics were burned by the Serbs. So we have this incredible variety. We have a variety of motives. And we’re just kind of at the cusp of trying to understand the varieties of this.

I think I agree with Yves, though, that the taboo applies in all these circumstances, whether it’s obstruction at checkpoints, whether it’s stopping convoys, whether it’s targeted bombing. We have to go back to the notion, which is over 150 years old with the Geneva Convention—what you don’t interfere with health care. It’s a very small statement—short statement, but it’s not—it has lost its power. And the antiterrorism has—counterterrorism strategy has also interfered with this, because the implicit assumption—and including by the United States—is that fighting terrorism, fighting for our security trumps other values. And that has resulted in an opening up of the kinds of activities that are inflicted, types of attacks on health care. So we’ve got this kind of range of kinds of motives, range of kinds of attacks. We have a long history. And now we have to figure out how we reverse that.

GARRETT: Why is it important to quantify all this? And why have we never seen anything relating to attacks on health reach The Hague or war crimes tribunal?

RUBENSTEIN: We need to quantify this to understand this. One of the problems of this issue is it has been under the screen. And when you talk to member states at the Security Council people want to know, is it getting better? Is it getting worse? How does it compare to five years ago? And the answer is, we don’t know because no one’s tracking the data. It’s like anything else. It’s like anything else in global health. You can’t make any progress in global health unless you know what the epidemiology is and you know what the data is. So we need to be able to track this. And we need to track it so we can understand it, so we can design interventions, so we can develop political will. That’s been a huge problem. Political will is the answer to many of these attacks, so that the Security Council resolution ends up meaning something.

And that’s why five years ago the coalition I chair pushed WHO to start collecting data, to require them to collect data. They’re still struggling to do that. This report was not based on primary data. We hope that’s what will happen, so that we have both real-time and longitudinal reporting to figure out how to address this on a pragmatic level, through preventive measures, and through accountability measures.

GARRETT: Kunduz. So before we get too far down the rabbit hole of thinking that this is somebody else’s doing, it was the United States military that bombed your facility—the MSF facility in Afghanistan, in Kunduz, which had demarcations on its rooftop indicating it was a health facility, and you had notified—MSF had notified armed forces of its location. Are you satisfied with the investigations that ensured and the penalties applied?

CONE: Well, I think the whole case of Kunduz sort of speaks to one of the things that Yves was talking about, how we see more and more battles being fought in densely populated and urban areas. And it’s part of, I think, a broader question of the shifting of burden of the responsibility of those with the lessons to make discerning choices about where they fire those weapons and what targets they choose to strike, and the sort of tests that they’re supposed to follow in terms of questions of precaution and proportionality and all these questions that come up.

What we see, I think, with the case of Kunduz, and I think it’s much broader than that, is this sort of worrying trends of the complexity of war, rules of engagement, rather than simplifying, making very clear a hospital is not a target. You know, that whole campaign is essentially about reminding us that that is—that is the starting point for the conversation. And it is not the burden of doctors, nurses, patients, to make their case. It’s actually—the burden falls on the combatants to make those choices.

So I think for us, yes, we never satisfied the question of—which is the broader accountability one—are there going to be independent investigations of these attacks? Are they going to happen—whether they be independent at a national or domestic level, or an international level? It should not be left to those who are responsible for the attacks or the victims to be the investigators, the juries, and the judges of these kinds of cases.

So that’s a fundamental piece, I think, of the follow-up to the U.N. Security Council resolution, is what does accountability look like? When did these incidents happen? Who’s going to discern what were the facts? What led to that? Because we can’t begin to start about the preventive measures and the corrective measures until we understand the circumstances of the attacks. And so, yes, the U.S. government’s done a very, I think, thorough investigation, but it doesn’t rise to the level of being independent and outside of the chain of command, in terms of the decisions that ultimately led to the accountability for various forces that were behind the decision making processes that led up to the attack.

I also want to point out just—I think it’s important because what Len has mentioned about, you know, tracking, finding the baseline for these attacks, that’s only to achieve a baseline for how many attacks are happening, who’s killed in the immediate aftermath or wounded. It doesn’t begin to tell us the story about the lives lost from the loss of services, right? The Kunduz trauma center was providing about 25,000 people with emergency medical services on a yearly basis over the four years that it existed in that part of Afghanistan. So we know, ever since that attack, that basically there’s probably anywhere from 3,000 to 5,000 people who had emergency surgery or limb-saving surgery in that hospital. Those people did not go away. Their needs did not disappear. Yet, the hospital’s there are not to serve them. They have to go much further. And we know how difficult it is in Afghanistan to get the kinds of services that the hospital rendered.

So the costs of these attacks are much more than the losses in the first—the immediate aftermath. They build and they built. And until we return the services, that’s never ameliorated. But I think it’s important that we really make some step forward with the Security Council resolution. What does accountability look like? What are the preventive measures that are put in place? Who are the checks and balances for those? So if the U.S. government tells me that they’ve retrained their soldiers, that there are efforts underway to re-clarify the rules of engagement, who’s the check on that? Is it Congress? Is it some international body? Who is the check on that? I mean, everything we talk about checks and balances in this world is predicated on authentic and audit and oversight. And where is that in the U.S.? Where is it elsewhere? Where is it with the Saudis, whoever? At least we can get it right with the states. I’m not going to pretend that we can get it right with the non-state actors.

GARRETT: Yves, it’s interesting because we have a similar trend of increasing attacks in violation of Geneva Convention against journalists. And everything to do with journalism has become far more dangerous. But it’s distinctly different. The journalists are more likely to be kidnapped by the mercenary groups, the militias, the drug cartels, and so on, while—and attacks are as pervasive on the Americas as they are in the Middle East, and Ukraine, and so on. In fact, the worst are in the Russian language speaking areas. And conversely, attacks on health are, you know, paramount, number one in the Middle East, with spillover in other places, and carried out by the state. Why is there this difference? And what does it say about where you search for solutions?

DACCORD: It’s interesting, because, Laurie, we do have a slightly different perspective than you do. And our perspective is not perfect, but it’s based in the fact that we do have people working in close proximity to people affected by war around the world. But we see the following one: When it comes to journalists, if I may start with that, I see journalists also being seriously under pressure in Africa, in some important places. I don’t see them in the Middle East.

And if I just can talk about for one minute Syria and Iraq, right now having journalists being able to report what is happening in area controlled by Islamic State group, I don’t see them at all. They are not able to be there, to be present, and it’s not new. I’ve seen also states putting a lot pressure on journalists. I think there’s a trend to have the ability of journalists not being there to report about what’s happening. And I think it’s very, very worrying. In a time where in fact party to the conflict being state and non-state armed group are willing to control absolutely the communication when it comes to the way they are running the show.

If I just say one minute on the Islamic State group, what strikes me is not so much the way they are fighting, it’s the way they’re communicating. They are possibly the only organization today which is able to control 100 percent of their own image. You would not see one photo about Islamic State group fighter which doesn’t come from themselves. I found that interesting, if you think about 21st century, right? Social media, everywhere. So they’re able to control communication. And what are they doing? They’re following state practice. So it’s not a question of state, non-state. It’s a question of when you fight a war you try to control, as much as you can, your communication.

And by the way, the same when it comes to health care. What we see, of course, it’s true, that states have been absolutely used, let’s say, as a strategy to systematically target hospital and health facilities, but not only states. If I look at Syria, for example, one dramatic today is the fact that all the parties to the conflict are moving and really putting enormous pressure on health care. But South Sudan, where is the state? Where are the non-state armed groups? I can tell you the level of violence against health care clinics, people, from parties to the conflict, I can’t distinguish the state and non-state.

So I think I understand what you’re saying, but I would be very careful not to look at trend around that. What I would be is then to be very specific context by context. There is responsibility. That’s very clear. States have responsibility and we should not shy away from that. But non-state armed group as well. And I really would put a lot of pressure, as well, on that. The question to us is what can we do? And here, as an organization, typically, we are deeply convinced that it is a—which is an important one—the question of accountability.

But that requires political will, right? And right now we live in a time where it’s difficult to get an international convergence to push for political will, right? And it will continue to be difficult. We still have to make sure that there is a push in that direction. At the same time, we cannot just wait this to happen. So as an organization what we are doing is we engage constructively, painfully, with states, but also with non-state armed groups. When it comes to health care we are deeply convinced that engaging on the daily basis, even with group as difficult as the Taliban—for example, when we talked about Afghanistan—or Al Shabaab in Somalia, or some of the non-state armed group in South Sudan or other places is critical.

It doesn’t mean it’s success, but we need to be able to find solutions with them, to try to sit at their table, try to influence their behavior on the daily basis. It’s not always perfect, but that’s the only way so far to be able to manage. With states it’s very different, because then you can really work on legislation, you can make sure that in their legislation, in their code of conduct, in their procedures in the army and training that it’s integrated. But it’s also very complex. So what I wanted to say is it’s a bit—your distinction between state and non-state armed group is not something I would pose to you as a trend, like you proposed.

GARRETT: Oh, so you just made it more difficult. (Laughter.) Thank you.

Len, let’s—I just want to—before opening to the audience here for their questions—to take an example of what happened with the Arab Spring. We saw a lot of uprisings taking place. Actually, we can go before the Arab Spring to the Green Revolution in Iran. And you often saw as there were confrontations between demonstrations and police forces or forces of the state clashes that resulted in injuries and sort of ad hoc hidden hospitals set up, in somebody’s living room, at a medical school, what have you, where courageous young health providers, often medical students, provided the necessary treatment, trauma care, for those who had been targeted.

And the result has been wholesale roundups, particularly the most extreme case perhaps in Bahrain, of huge numbers of health providers designated as terrorists for having provided care to these injured demonstrators. And some of them we’ve completely lost track of. They have been absorbed by the state. They have been tortured. And who knows if they’re even still alive. This is a trend—I mean, the only one—the only profound example of this I can think of in recent history would be Tiananmen massacre and all the health providers in Beijing.

What is the take-home lesson? And when we talk about accountability, Yves laid out an accountability paradigm that assumes conversation with the state can lead to some kind of, you know, re-ratification, if you will, of the essence of the Geneva Convention. But if the state is the responsible actor, what do we do?

RUBENSTEIN: This is a huge problem. And it was—in the Arab Spring there were medical tends in Tahrir Square. And they were attacked. Last year, in 2015, there were two Turkish doctors convicted of the criminal offense for providing health care to demonstrators in the Gezi Park protest. The charge was they went into a mosque with their shoes on, that was the pretext. The United States criminalizes health care to terrorists. So we have a problem that people at various levels who are considered enemies are targets, with a war or without a war. And that’s part of the problem. And that’s why it’s so important that not just humanitarian law, but human rights law applies.

So have this problem. I agree with Yves. It’s not just states. In fact, in Africa you have these horrific attacks on health care going on in Central African Republic and Mali and South Sudan, more at the behest of the state. So it’s a phenomenon. But, we have to get to the point where this can’t be tolerated as a policy of government. And to end kind of on a hopeful note, a few years ago this wasn’t on anybody’s screen. That’s why I’m so glad, Laurie, you organized this. That with the Security Council resolution, with the discussion at the World Humanitarian Summit, with discussions like this I think there can be growing awareness that this is a major issue that undermines health care, that undermines the integrity of the medical profession and the nursing professions and all other health workers, and puts patients at huge risk. So we have to change that mindset. And now may be the time to really start.

GARRETT: Yves, you do two-finger.

DACCORD: Yeah, I just wanted to say, in sharing absolutely with Len, I think we’ve raised now an interesting moment of awareness. I think it’s now moving into more policy and trying to influence. And it’s also language. And here, I just wanted to make a link. It was interesting to follow. If you look at the U.N. Resolution 2286, it’s a resolution with the power of resolution. And also, of course, it’s interesting when you implement it, but language is important.

For the first time, and I’ve seen that just today at ECOSOC right now, it also says very clearly: You can’t punish anybody engaged in medical activities based, you know, on foreign medical ethics. This is language a few weeks ago you could not find in the U.N. And I found it interesting that when you start to build consensus around language, it’s still not policy, but it starts to get traction. And there’s a long way for us to run. And maybe the message is it’s multiple solutions, trying to find everywhere we can a little bit of space to push it back to try to find and to fight back, in a way, these policies.

RUBENSTEIN: OK, and I didn’t answer one of your questions. OK, you asked about The Hague. We need, as part of the accountable, to hold people criminally accountable. These are war crimes. There’s no doubt about it, that in these situations of armed conflict they’re war crimes. There has been no prosecution. There was one case back in the war in former Yugoslavia where there was a prosecution concerning people who were murdered who were taking refuge in a hospital. But it wasn’t specifically around the provision of health care. We need to do that.

And to me, the problem with Kunduz wasn’t simply that there wasn’t—or it wasn’t that it wasn’t an independent investigation. It was a very thorough Pentagon investigation, and under principles of criminal justice internationally the state who has jurisdiction originally should do the investigation, which they did. And then, they didn’t prosecute anybody. They could have held—tried to hold soldiers in breach of the Uniform Code of Military Justice for gross negligence. But they chose not to do this, and issued simply administrative sanctions. That, I think, is the wrong message. And that is what is problematic about accountability in that case. And we don’t have any other cases.

GARRETT: All right. I’m going to open it up for questions. Please raise your hand if you would like to ask a question. Wait for the microphone. And be sure to identify yourself when you make your question. Do I see any questions in the audience? In the back there.

Q: Hi. I’m Joel Simon. I’m the executive director of the Committee to Protect Journalists.

So I want to take—you raised a parallel between the threats to journalists and health care workers in conflict zones. And I would—our data suggests that this is the most deadly and dangerous time for journalists ever, record numbers of journalists killed, record numbers of journalists imprisoned, and the threat is from state and non-state actors, as you suggest. And in my view, what’s made this moment particularly dangerous for journalists is the way the technology has transformed journalism. And it means that journalists are less valuable, less useful to the parties of the conflict, and therefore more vulnerable. And it’s never been respect for international norms, it’s been the utility that journalists have had in conflict zones that has kept them safe.

Has something changed for health care workers in conflict zones? Is there some parallel that has made them less useful to the parties to the conflict, and therefore more vulnerable, and has led to this increase?

GARRETT: A really important question. Jason, in our conversation yesterday before we gathered here you had suggested—I think it would build on his question—that the shift towards the war on terrorism, the sort of post-9/11 culture has been a very significant threat to the neutrality of health workers. Can you expand on that?

CONE: Yeah. I think—I mean, there are really—to really simplify, I think there are really two things that normally in these environments keep an MSF, or I would say an ICRC, or other teams safe. One is, normally for us—Syria is really an outlier—transparency and visibility. The fact that we’re present and here we’re here, we’re here just to treat people. The other side is the usefulness of our operation. So are we providing something that’s meaningful in terms of the community that we’re serving, in terms of medical care? And let’s be honest, the fact that we’re providing—we’re willing and able to provide services to wounded combatants as part of our ethical responsibilities also makes us somewhat useful to different sides of the conflict.

But I think, as Yves said, we have to look at these things context by context. You take South Sudan, a place I was about three years ago, oftentimes medical care was accepted in largely ethnically and tribally homogenous areas of the country. So you have the MSF hospital running in the Nuer territory. When there was fighting and the territory shifted to another tribe, oftentimes the hospitals would become attacked, not because it was MSF, not because necessarily health care, but it was part of a scorched Earth kind of strategy. And you can see this play out in different places. You have the Rohingya in Myanmar, right, who are systematically denied access to health care. But it’s not just the question of the state, but it’s also a question of local communities who don’t accept the fact that the Rohingya, a Muslim population, should have access to these services in certain parts of the country.

Take the war on terror. Yes, counterinsurgency and the kind—the way these things are playing out, you know, for us one of the key things is keeping weapons out of the hospital. It makes patient feel safe. It makes sure that they’re not seen as places for bait in terms of—but there are aspects of the Geneva Conventions that allow people to—allow armed groups to come and take the wounded and sick, as long as they provide health care for them. But that could also be used for quite nefarious purposes when it comes to potentially targeting a high-value target for—on one side or the other. So how are these loopholes used in some ways that can expose both the medical providers to risk, but also the patients. And if people believe that you can burst into a hospital at any moment and have a patient taken away, that in essence throws the value of the hospital there, because the population will just not go.

GARRETT: You know, you’re raising a point that I do think is in common with journalism. I remember the moment when I was covering the Persian Gulf War when the issue arose: Should people—should a journalist wear a flak jacket? It seems naïve today—you know, oh, the quaint days when we actually questioned waring flak jackets. But the idea was, if you’re wearing one then doesn’t it look like you’re identifying with security? And if you’re identifying with security, will the average civilian feel they can speak to you comfortably?

Today, flash forward in the debate among journalist organizations and among health organizations is, do you hire armed security? If you’re a reporter, do you travel with somebody who’s carrying guns? If you’re a clinic trying to operate, or it’s—you’re a Red Crescent convoy trying to conduct penicillin to a location, do you do so with armed guards, hired mercenaries, you know? But this is a huge change. It wasn’t even a conversation point 10 years ago. So, Yves, where do you go with this?

DACCORD: Back to basics. That’s where we go. Which means, in fact, that if you allow yourself to be protected against people somewhat, and against combatants, your protection is very limited. How do you protect yourself within Syria? Imagine what would mean that, to have a bodyguard in Syria. By whom? How is that organized? You think about the realistic element of that. So as an organization if you want to maintain proximity—this is very clearly something we share with MSF—they said numbers are fools. A, you have to agree that you have to demonstrate principle. The burden of proof, it is sad to say, that is on us. This is what has shifted.

Before we could say: I’m the Red Cross. Trust me. And I would say in 99 percent of the case, people would trust you. Today you say: I’m the Red Cross. I’m neutral. I’m impartial. People will tell you, prove it, to me—prove. And it is not new, but this is really starting a trend. So as an organization, what you have to rethink is how do you demonstrate that on a daily basis. And here, if I may just say one word, it’s about our people management. We have to radically change the way we look at our human resources, radically.

One thing we have really realized is we have to maintain what I would call a virtuous circle. A virtuous circle is which one? Is the day if you start to be protected by your own security, you quickly cut yourself from the people, right? You have to know the choices, because will have to have more people protecting you, guarding you more. And some of you are working in the U.N., and you know very well that 10 years ago the U.N. make a strategic choice to centralize security management in New York, right? So New York decides if you can move out or not from your bunker.

We did exactly the contrary. We strategically made the choice that our team on the ground would decide on security and they would prevail on me, because they know it. They know the relationship management. But then the deal is the following one. My expectation is that they will engage, try to find solutions, be open and transparent. But it’s very, very—it takes a lot of time. Syria is a good example. Forty-eight nationality cannot be deployed. So when I’m saying my team will be in Syria and is working, and of course not just in Damascus, in Aleppo and other places, it means will not only work with locally hired people. I cannot just outsource the risk to my local community. That doesn’t work.

So you need to have international and national staff together, back to people management. But you need to have people very competent, knowing the organization, but also from the right nationality. If I’m looking at you, ladies and gentlemen, sadly your world has shrunk. My world has shrunk too. As an American or as a European right now, I can’t use you in the Middle East. If you be Danish—do we have a Danish here? Just to give you, it’s not just you or me, Danish, for example, very difficult. I would not take the risk to have one of my colleagues from ICRC being Danish right now in the Middle East.

So we have—we have changed the world in which being able to not only looking at what is happening, but we have to be very concrete trying to find solutions. But last but not least, despite of the new technologies, we still believe in the human contact. We still believe that sitting with somebody at his table, or at her table, is still the right way—engaging, and not being afraid by labelization. So when people are talking about terrorists, we now it’s criminal activities, but we will still try to engage to find solution on a pure humanitarian basis.

GARRETT: Well, and of course, that’s obviously true in journalism.

DACCORD: Exactly.

GARRETT: Nothing beats the eyewitness. Nothing. But if the danger of being the eyewitness is so profound then—you know, one of the things we hear automatically when someone is kidnapped is, oh, you know, he took excessive risks. Or, you know, he didn’t have a good bodyguard. Or he didn’t have a decent translator. In other words, it’s almost like it’s his fault that he got kidnapped.

Do we have other questions? Sheri. Please identify yourself.

Q: Sheri Fink.

I just wanted to push back on this idea that this is new. I remember in Bosnia the ICRC faced some questions about whether to use security. You know, in Iraq it was a huge issue about—and very controversial, whether aid groups working 2003 would use security. And just these violations of medical neutrality that we were talking about so much in the ’90s. So I guess my question is, like, why are we still having this conversation? And has anything changed for the better at all? And I don’t know, just anything you want to say.

GARRETT: So bottom line—bottom line is, is the trend—is there a worrying trend? Is this actually worsening? And why have past conversations failed to slow it down?

RUBENSTEIN: Well, as I said before, I don’t think this is new at all. Like, no one was paying attention. I think one of the things that is new is that you have had a major state, Syria, targeting health care in a systematic way—300 attacks on hospitals over the course of a year, plus, as a part of its strategic objectives. In the past, I think most attacks on health care—and this is an overgeneralization—had to do with a difference to the rules, as opposed—that is, there was a political or military objective, they wanted to force the population, they wanted to do ethnic cleansing, they wanted to accomplish some goal. And civilians, including health care, was attacked.

But what is different, I think—and Syria is a very unique, scary, and concerning case, because it’s the major case. And it kind of sets the tone if there has been in the way these attacks are looked at by other states. That is the change. Another change, I think, is there is—is in the level of cooperation. ICRC, even though it existed for 35, 40 years, has been working with armed groups to do vaccinations. And a lot of people are surprised to hear that in Afghanistan actually the Taliban cooperated in vaccination campaigns, and Mullah Omar wrote a letter to his commanders saying please cooperate, we’re doing a vaccination campaign. It was an extraordinary achievement to provide health care.

But that’s getting harder and harder, I think. In Pakistan, that’s impossible. In many other countries it’s getting harder and harder. In Nigeria, there was a lot of controversy about vaccinations in the past. But now, you can’t talk to Boko Haram. And by the way, 450 hospitals in northern Nigeria are out of service because of the conflict in northern Nigeria. So that, to me, is the difference. It’s the kind of willingness to be overtly and strategically attacking health care.

GARRETT: It seems like you’re saying, well, we used to say, oh, gee, that was a health facility? Oh, so sorry, didn’t mean to bomb that. Now it’s, we will bomb because you’re a health facility.

RUBENSTEIN: Right. And it’s not even. It’s not like it was a golden age, to say the least. But I think Syria really changes the calculus.

GARRETT: Yves, you were trying to add a comment?

DACCORD: No, just to mention that I totally agree. And I think what we have to be careful is there is some things which have changed in terms of scale, in terms of systematic practice from old side. And again, I want to insist, Syria has made a change in terms of the vast amount from day one of the conflict. But if you go across the board right now, in Yemen, in Afghanistan, in South Sudan, in Somalia, they have very different contexts. And you feel absolutely normal practice today to target, in fact, health worker, very clearly patient. Universal access to health is a huge issue today, which is unbelievable. Twenty years ago it was a big issue, but we thought we were improving. So the worry is, in fact, there have been no improvements, whereas technology should have allowed us to have access much more easy. You could provide health to people much more directly today. You can’t. And it is what is so frustrating and so worrying as a trend.

GARRETT: Let’s give a chance for another question. Over here.

Q: Thank you. Joanna Weschler with Security Council Report.

 The word accountability came up several times during this very interesting conversation. And you, Laurie, mentioned the case of Bahrain, where there was this absolutely unprecedented repression aimed at medical personnel for essentially doing their job. And there was probably very little to none of accountability. But there was not even a reaction, for instance, allies of Bahrain saying, OK, you cross a certain line you don’t do it. You mentioned yourself that we don’t know where these people who were sentenced and thrown in prison are today. They were kind of lost by everybody.

Now, Kunduz—I think the tragedy of Kunduz created a situation in which some line has been crossed irrevocably. And probably the face that there was this resolution in the Security Council had something to do with what happened in Afghanistan. My question is, the three of you who somehow contributed to this resolution happening and your bosses, meaning MSF and ICRC, had made some powerful statements outside of the Security Council, what happens next? Will you be able to use that document in any way to actually see accountability to really happen in the case of Kunduz and to really happen in any next case, which probably, unfortunately, will happen?


CONE: Well, I think that there are some steps that are follow up. Some of it is giving visibility in a more systematic way to the attacks. So some of the work that is coming out both of the World Health Assembly in terms of the tracking, some of the epidemiology of the violence that Len was alluded to. For us, I think, there is—you know, as I mentioned earlier, the importance of independent fact finding. We can’t—you know, there is—a lot of what stems around the argument around Kunduz is the question of intent. You know, is intent the sort of most important aspect of this?

And I think what’s more worrying actually is—because we see intentional acts playing out every day in Syria—is the notion that there’s no stopping of the battlefield. That, like, a recklessness in terms of the pursuit of military objectives, it forces civilians to get out of the way of bombs to be put themselves outside, hospitals to be, you know, moved away from so-called military objectives, when those of us who try and run hospitals in conflict settings have no pretense of knowing what today is a military objective and what isn’t tomorrow. The way these kinds of conflicts are playing out in densely populated areas, the gray zones that have sort of emerged around the calculus of what is acceptable human loss to, you know, obtain a military objective.

I think there needs to be a bit of a feedback loop. And one would hope from the resolution is that states will not only—not only will have reporting, but states will actually have to come forward and explain how they’re addressing these issues in a much more overt way. Maybe that’s too ambitious, but one could argue it’s a nice starting point to count the attacks and who’s responsible for them. But what actually are states doing, when we have many wars playing out that are coalition led. So who will be responsible? Who’s in the air today over Syria, versus over Yemen, and where is next—Libya, right? So who’s responsible for these attacks? It’ll be very murky. You’ll have armies working with different rules of engagement, following different kinds of interpretations of the laws of war.

That’s a very dangerous place to be a health worker, particularly a national health worker, and also to be a patient. We have patients who don’t want to come to our hospitals anymore, because they see them as targets rather than places of healing. And that’s where the resolution has to gain some teeth, is scratching back that aspect and, for us, pushing the violence outside the clinic door as a minimum for the frontline for us.

GARRETT: Let me pose the possibility—I’ll put it to Yves and Len—that, you know, we had a U.N. Security Council resolution denouncing Damascus for using chemical weapons on their population. And there was this claim, you know, there’s a line in the sand and blah, blah, blah. There shall be retribution. And now, chlorine gas is used so routinely in Syria that it’s really rarely singled out for any reporting of any kind. It’s just become another weapon. The risk here is that we underscore through this U.N. process the unreasonable hazards that health facilities and health workers face, then no steps are taken. And it becomes just like chlorine gas, another final element of warfare. Yves.

DACCORD: Yes and no. I see your point. And I think there is a real—I think there is a real issue about being aware that it’s not because you have a U.N. resolution of the Security Council that everything will change from one day to another. And I think we agree with that. On the other hand, I think here, I mean, you can also look at—it still shapes somewhat the political agenda of the international community. And what was the problem with in fact some of the weapon used, and especially when it comes to Syria? There was never, ever any convergence between members of the Security Council to make it happen. There is no political convergence to deal with the conflict of Syria. That’s very clear. We knew from day one this conflict will not be solved by Syria. That was very clear.

And even until today you have no political convergence. And people are aware—very much aware—when there is no political convergence that you can play with the rules and you can push it as much as you can. On health care and danger, I might be a little bit too optimistic, but I think there is minimum of convergence. And it is our job to start to create this convergence. Can I just say one work—and what something, Len, you have done a lot, and I think we try now to help that. One thing we totally underestimate at a time—and you ask what is new—I think we thought it was our issue, right? We, ICRC or MSF or maybe Len, so kind of we were trying to find solutions. And we started to realize, my God, I mean, this cannot be just our issue. We have to really raise not only state and non-state armed group, but also to the community of concern.

And this is what strikes me so much, is you have a lot of doctors, nurses, you know, professional of health not aware of the problem—really not aware, or not very much aware, right, or not interested. Today, with, I would say, the resolution of the U.N. Security Council, not only, with the report, with the dynamic created, if we push you have 30 million professional of health care being mobilized around the question. This powerful if we are able to move in that direction. So I think what I’m saying is it seems to me still we can create a minimum of convergence between states. I have the impression that states start to understand this is really the minimum they have to look into that, right?

I think new technology, which was talked before, will may be help us. It’s easy today to really follow very carefully what’s happening in each of the health posts and clinic around the world. So if I project myself in five to 10 years, I think it will be a very hard and complex and bumpy road, but I have the feeling that if we’re able to create this convergence, you know, push that at the really high level in the agenda, and not expecting one country or the other to solve all the problems but trying to find solutions and convergence with the help of the community of concern, my sense is we will move in the right direction—painful, very difficult, but I’m a little bit more optimistic that I’m—if I regard to you, as for journalists, for example.

GARRETT: Well, I’m afraid that’s going to have to be our end note. I’m sorry, Len, but we always end on time.


DACCORD: A moment for Len, please.

GARRETT: I’m sorry. It’s a Council rule. We always end on time.

DACCORD: Oh, sorry about that.

GARRETT: At least then we’re ending on an upbeat note. And I would just urge all of you to pass onto your friends and colleagues that this webcast will remain on the CFR website for their viewing for some period of time. And thanks to all of our panel. Let’s give them a big hand. (Applause.) Thanks to the Council.


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